Download Onward Referral of Adults with Hearing Difficulty Directly Referred to

Guidance for Audiologists:
Onward Referral of Adults with
Hearing Difficulty Directly
Referred to Audiology Services
Produced by:
Service Quality Committee of the British
Academy of Audiology
Key Authors:
Hanna Jeffery
Suzanne Jennings
Laura Turton
Date of publication:
November 2016
Review date:
November 2021
BAA – Service Quality Committee
Acknowledgements
The Service Quality Committee would like to thank all those who provided their opinions on the draft of
this document sent out for consultation, including BAA members, The British Society of Audiology, The
British Association of Audiological Physicians, ENT UK and The Royal College of General Practitioners.
This document is a British Academy of Audiology document and has not been endorsed by any other
organisation.
Introduction
This document is intended to guide Audiologists in service planning and in making referrals for a medical
or other professional opinion.
Along with “Guidelines for Primary Care: Direct Referral of Adults with Hearing Difficulty to Audiology
Services (2016)1”, this document replaces the earlier guidelines (BAA 20092, TTSA 19893,4) and has
been approved by the Board of the British Academy of Audiology.
This document comprises a set of criteria which define the circumstances in which an Audiologist in the
UK should refer an adult with hearing difficulties for a medical or other professional opinion. If any of
these are found, then the patient should be referred to an Ear, Nose and Throat (ENT) department, to
their GP or to an Audiologist with an extended scope of practice. The criteria have been written for all
adults (age 18+), but local specifications regarding age range for direct referral should be adhered to.
This document is intended to be used in conjunction with “Guidelines for Primary Care: Direct Referral
of Adults with Hearing Difficulty to Audiology Services (2016)1”. Audiology services are expected to
make reasonable efforts to make local GPs aware of this guidance and support their understanding of
its application.
A simple checklist has been included as an appendix, to summarise the criteria detailed in this
document.
Background
In the past, direct referral guidelines were written to provide a simple pathway to hearing aid provision
for older adults (age 60+) with routine hearing loss. The age range for direct referrals now varies
between services. Some Audiology services are taking direct referrals from age 162, but most take
referrals from age 18 or age 50.
The criteria in this document are well accepted both in the UK and internationally5,6,7. Where no
published evidence is available, the criteria have been based on clinical consensus and agreed by the
appropriate professional organisations. We recommend further research to provide a robust evidence
base to support future guidance.
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Regional Variation
The criteria listed in this document are considered to be best practice. However, the ways that
Audiologists receive referrals and the services available for onward referral vary according to individual
working circumstances and region.
Local arrangements may be in place for the direct referral of other conditions to Audiology, such as
tinnitus, balance problems and auditory processing difficulties. Practitioners are encouraged to make
use of specialist pathways which may be more appropriate, or can be used as an alternative to ENT
referral8*. These referral routes are outside the scope of this document, but Audiology services are
encouraged to have additional protocols to allow for regional differences in referral pathways.
Local guidelines for referral into some pathways may include specific criteria in addition to those
included in this document.
Scope of this Document
Audiology services are encouraged to have policies in place regarding the referral of existing hearing
aid users into the Audiology service. It is best practice to work with other local providers to ensure a
consistent approach when designing these policies.
Existing hearing aid users may be referred to ENT on the basis of the criteria in this document. However,
detailed guidance on pre-existing conditions, previous investigations and the deterioration of hearing
are beyond the scope of this document.
Audiology services are encouraged to have policies in place regarding the monitoring of adults with
medical conditions which predispose them to rapid deterioration in hearing.
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BAA – Service Quality Committee
Prerequisites for the Assessment of Adults with hearing loss
Direct referral assessments must be conducted by a suitably qualified Healthcare Science Practitioner.
For further guidance, see the current BAA Scope of Practice Document8*.
This will usually be:

A qualified Audiologist, registered with the Registration Council for Clinical
Physiologists (RCCP) or Academy of Healthcare Science (AHCS).

A Clinical Scientist (Audiology), registered with the Health and Care Professions
Council (HCPC).

A Hearing Aid Dispenser, registered with the HCPC.
This document uses the term Audiologist to refer to all of these roles.
Notes on the onward referral of adults by an Audiologist
If any of the following criteria become evident on assessment in Audiology, a medical opinion should
be sought. Depending on local protocol, this referral will usually be to an Ear, Nose and Throat (ENT)
department, Audiovestibular Medicine or to the GP. Where available, this may also be to an Audiology
practitioner with an extended scope of practice. The reason(s) for onward referral should be explained
to the patient and the referral made only after obtaining their informed consent. Pre-existing and
investigated (medical) conditions should be taken into account, if relevant.
All findings and advice given must be recorded and the patient’s GP informed of the outcome. This
includes any onward referrals which have been made, or to inform them that a referral was
recommended but consent declined.
In some services it is not possible for the Audiologist to refer directly to ENT. In this instance, a copy of
the findings and the reason(s) onward referral is indicated should be issued to the patient and to their
GP, with the patient’s consent. The GP should then refer to ENT, including the information provided by
the Audiologist.
Some Audiologists may have an extended scope of practice and provide pathways which substitute for
medical referral. They must always operate within their defined professional role, according to their
regional and/or professional protocols. Examples include:

Audiologists removing ear wax.

Undertaking vestibular function and tinnitus assessments followed by delivery and
review of appropriate rehabilitation programmes.

Assessment and consideration of audiological suitability for implantable hearing
devices.

Requesting MRI scanning in the case of an asymmetrical sensorineural hearing loss.
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BAA – Service Quality Committee
Referral for a medical opinion should not normally delay impression taking or hearing aid provision. The
Audiologist must make a professional decision, based on ear examination, whether it is safe to proceed
with impression taking9 and/or hearing aid fitting.
It is acknowledged that it is not always clear which adults require onward referral. Audiologists are
expected to make a professional judgement, including seeking the opinion of colleagues who are more
experienced, or who have specialist expertise, when appropriate.
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BAA – Service Quality Committee
Criteria for onward referral by the Audiologist
History:
Sudden loss or sudden deterioration of hearing (sudden = within 72 hours), unilateral or bilateral,
should be sent to A&E or Urgent Care ENT clinic within 24 hours. Due to the variety of causes of sudden
hearing loss, the treatment timescale should be decided locally by the medical team. Prompt treatment
may increase the likelihood of recovery10,11,12.
Altered sensation or numbness in the face13 or observed facial droop. Urgent medical advice should
be sought if these symptoms have not previously been investigated.
Persistent pain affecting either ear, which is intrusive and which has not resolved as a result of
prescribed treatment. (As a general guideline, this includes pain in or around the ear, lasting a week or
more in recent months).
History of discharge (other than wax) from either ear within the last 90 days, which has not resolved
or responded to prescribed treatment, or which is recurrent.
Rapid loss or rapid deterioration of hearing (rapid = 90 days or less)14.
Fluctuating hearing loss, other than associated with colds.
Hyperacusis. (An intolerance to everyday sounds that causes significant distress and impairment in
social, occupational recreational and other day to day activities).
Tinnitus, which is persistent and which:

is unilateral

is pulsatile

has significantly changed in nature

is leading to sleep disturbance or is associated with symptoms of anxiety or depression
(For further guidance on the referral of adults with tinnitus, please see related evidence 15,16,17).
Vertigo which has not fully resolved, or which is recurrent. (Vertigo is classically described as a
hallucination of movement, but here includes any dizziness or imbalance that may indicate otological,
neurological or medical conditions. Examples include headaches with associated dizziness, spinning,
swaying or floating sensations and veering to the side when walking. For further guidance on vertigo,
see www.vestibular.org18).
Normal peripheral hearing, but with altered auditory perceptions or abnormal difficulty hearing in
noisy backgrounds. This may include having problems with sound localisation, the perception of pitch
and loudness or difficulty following complex auditory directions 19,20.
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Ear examination:
Complete or partial obstruction of the external auditory canal preventing full examination of the
eardrum and/or proper taking of an aural impression. If wax is obscuring the eardrum or there is a
current infection, local wax care or treatment procedures should be followed.
Abnormal appearance of the outer ear and/or the eardrum (Examples include21: inflammation of the
external auditory canal, perforated eardrum, active discharge, eardrum retraction, abnormal bony or
skin growths, swelling of the outer ear or blood in the ear canal).
Tympanometry (performed if there is any indication of middle ear
effusion):
Unilateral flat tympanogram, regardless of the associated level of hearing loss22,23.
Audiometry:
Conductive hearing loss, defined as 20 dB or greater average air-bone gap over three of the following
frequencies: 500, 1000, 2000, 3000 or 4000 Hz24,25. A lesser conductive hearing loss in the presence
of bilateral middle ear effusion may be referred at the discretion of the Audiologist 26.
Unilateral or asymmetrical sensorineural hearing loss, defined as a difference between the left and
right bone conduction thresholds (masked as appropriate) of 20 dB or greater at two or more adjacent
frequencies: 500, 1000, 2000, 4000 or 8000Hz. (Other frequencies may be included at the discretion of
the Audiologist)27,28,29. In the absence of recordable bone conduction thresholds, air conduction
thresholds should be considered instead.
Evidence of deterioration of hearing by comparison with an audiogram taken in the last 24 months,
defined as a deterioration of 15 dB or more in bone conduction threshold readings at two or more of the
following frequencies: 500, 1000, 2000, 3000 or 4000 Hz. In the absence of recordable bone conduction
thresholds, air conduction thresholds should be considered instead.
Other findings:
Any other unusual presenting features at the discretion of the Audiologist or according to the
requirements of the service to which the adult is being referred. Audiologists are expected to use their
professional judgement and relevant guidance to make appropriate onward referrals for adults requiring
Audiology services beyond their own scope of practice (for example, due to hearing loss complexity or
co-existing conditions30). Such referrals may be made in addition to a referral for a medical opinion.
Adults with sensorineural hearing loss which does not appear to be age related should, where
appropriate, be offered a referral for aetiological investigation31.
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Conclusion
This document has listed the criteria for Audiologists to consider when assessing adults with hearing
difficulties who have been directly referred (or self-referred) into the Audiology service. This should
ensure that adults receive further assessment and care, with the correct professionals, when it is
appropriate.
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Bibliography
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British Academy of Audiology. 2016. “Guidelines for Primary Care: Direct Referral of Adults with
Hearing Difficulty to Audiology Services” [Online]. Available at:
http://www.baaudiology.org/about/publications/
2
British Academy of Audiology. 2009. “Guidelines for Referral to Audiology of Adults with Hearing
Difficulty,” [Online]. Available at: http://www.baaudiology.org/about/publications/
3
British Association Audiological Scientists. 1989. “Criteria for direct referral: Guidelines of the Liaison
Group of Technicians, Therapists and Scientists in Audiology (TTSA)”. BAAS Newsletter.
(A copy can be found within “Hearing and Balance Disorders; Achieving excellence in diagnosis and
management”4)
4
Royal College of Physicians. 2007. “Hearing and Balance Disorders. Achieving excellence in
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NHS Scotland. 2006. “Guidance for the Direct Referral of Patients to Audiology Services” [Online]
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British Society of Hearing Aid Audiologists. 2014. “Guidance on Professional Practice for Hearing
Aid Audiologists” [Online]. Available at:
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8-ca7c-4f08-8a84-364468a02a28 [Accessed December 2015]
7
J R Steiger. 2005. “Audiologic referral criteria: Sample clinic guidelines,” Hearing Journal, Volume
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November 2015]
*(Please note that this is under review at the time of writing and the latest version should be
consulted.)
9
British Society of Audiology. 2013. “Recommended Procedure: Taking an Aural Impression”
[Online]. Available at: www.thebsa.org.uk/wpcontent/uploads/2014/04/BSA_PPC_RP_Impressions_FINAL_12Feb2013.pdf
10
M Kuhn, S E Heman-Ackah, J A Shaikh, P C Roehm. 2011. “Sudden Sensorineural Hearing Loss:
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91–105.
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Neuroma”.
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K C Campbell, J J Klemens. 2000. “Sudden hearing loss and autoimmune inner ear disease,”
Journal of the American Academy of Audiology. Volume 11, issue 7, pp. 361-367.
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National Institute for Health and Care Excellence. 2010. “Tinnitus”. [Online]. Available at:
http://cks.nice.org.uk/tinnitus#!scenario [Accessed Sept 2015].
16
British Tinnitus Association. 2012. “Primary Care Tinnitus Consultation,” [Online] Available at:
www.tinnitus.org.uk/eight-minute-primary-care-tinnitus-consultation
17
Department of Health. 2009. “Provision of Services for Adults with Tinnitus. A Good Practice
Guide,” [Online] Available at:
http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/Publicationsands
tatistics/Publications/PublicationsPolicyAndGuidance/DH_093844
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Vestibular Disorders Association. “What are the symptoms of a Vestibular Disorder?” [Online].
Available at: https://vestibular.org/understanding-vestibular-disorder/symptoms [Accessed September
2015].
19
NHS. 2015. “Auditory Processing Disorder” [Online]. Available at: www.nhs.uk/conditions/auditory-
processing-disorder/Pages/Introduction.aspx [Accessed November 2015].
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25
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27
P J Dawes. 2001. “Vestibular schwannoma screening: closing the audit loop,” Journal of
Laryngology Otology. Volume 115, pp. 719-722.
28
R J Obholzer, P A Rea, J P Harcourt. 2004. “Magnetic resonance imaging screening for vestibular
schwannoma: analysis of published protocols.” Journal of Laryngology and Otolaryngology. Volume
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29
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30
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31British
Association of Audiovestibular Physicians. 2015. “Aetiological investigations into
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Appendix – Onward referral of patient by an Audiologist (summary)
History
Sudden loss or sudden deterioration of hearing
Send to A&E or Urgent
Care ENT clinic.
(Sudden = within 72 hours)
Altered sensation or numbness in the face, or facial droop
Yes / No
Persistent pain affecting either ear
Yes / No
History of discharge (other than wax) from either ear within the last 90 days
Yes / No
Rapid loss or rapid deterioration of hearing (rapid = 90 days or less)
Yes / No
Fluctuating hearing loss, other than associated with colds
Yes / No
Hyperacusis
Yes / No
Tinnitus which:
Yes / No
is unilateral
is pulsatile
has significantly changed in nature
is leading to sleep disturbance or is associated with symptoms of anxiety or
depression.
Vertigo which has not fully resolved or which is recurrent.
Yes / No
a hallucination of movement
any dizziness or imbalance that may indicate otological, neurological or
medical conditions
examples include headaches with associated dizziness, spinning, swaying or
floating sensations and veering to the side when walking
Normal peripheral hearing, but with altered auditory perceptions
Yes / No
Ear Examination
Complete or partial obstruction of the external auditory canal preventing full
Yes / No
examination of the eardrum and/or proper taking of an aural impression.
Abnormal appearance of the outer ear and/or the eardrum
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Yes / No
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Tympanometry (if performed)
Unilateral flat tympanogram, regardless of the associated level of hearing loss.
Yes / No
Audiometry
Conductive hearing loss
Yes / No
20 dB or greater average air-bone gap over three of the following frequencies: 500,
1000, 2000, 3000 or 4000 Hz. A lesser conductive hearing loss in the presence of
bilateral middle ear effusion may be referred at the discretion of the Audiologist
Unilateral or asymmetrical sensorineural hearing loss
Yes / No
A difference between the left and right bone conduction thresholds of 20 dB or greater
at two or more adjacent frequencies: 500, 1000, 2000, 4000 or 8000Hz. (Other
frequencies may be included at the discretion of the Audiologist).
Evidence of deterioration of hearing by comparison with an audiogram taken in
Yes / No
the last 24 months
A deterioration of 15 dB or more in bone conduction threshold readings at two or more
of the following frequencies: 500, 1000, 2000, 3000 or 4000 Hz. In the absence of
recordable bone conduction thresholds, air conduction thresholds should be
considered instead.
Other
Any other unusual presenting features at the discretion of the Audiologist. Please give
Yes / No
details below:
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